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  • 1.
    Dobrydnjov, Igor
    et al.
    Departments of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Axelsson, Kjell
    Departments of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Berggren, L.
    Departments of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Samarütel, J.
    Tartu University Hospital, Tartu, Estonia.
    Holmström, B.
    Departments of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Intrathecal and oral clonidine as prophylaxis for postoperative alcohol withdrawal syndrome: a randomized double-blinded study2004In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 98, no 3, p. 738-744Article in journal (Refereed)
    Abstract [en]

    In this study, we evaluated the effect of intrathecal and oral clonidine as supplements to spinal anesthesia with lidocaine in patients at risk of postoperative alcohol withdrawal syndrome (AWS). We hypothesized that clonidine would have a prophylactic effect on postoperative AWS. Forty-five alcohol-dependent patients (daily ethanol intake >60 g) scheduled for transurethral resection of the prostate were double-blindly randomized into three groups. All patients received hyperbaric lidocaine 100 mg intrathecally. The diazepam group (DiazG) was premedicated with diazepam 10 mg orally; the intrathecal clonidine group (Cloni/tG) received a placebo (saline) tablet and clonidine 150 μg intrathecally; and the oral clonidine group (Clonp/oG) received clonidine 150 μg orally. For patients diagnosed with AWS, the Clinical Institute Withdrawal Assessment for Alcohol, revised scale, was used. Twelve patients in the DiazG had symptoms of AWS, compared with two in the Cloni/tG and one in the Clonp/oG. The median Clinical Institute Withdrawal Assessment for Alcohol, revised scale, score was 12 in the DiazG versus 1 in the clonidine-treated groups. Two patients in the DiazG had severe delirium. Patients receiving oral clonidine had a slightly decreased mean arterial blood pressure 6–12 h after spinal anesthesia (P < 0.05); patients in the DiazG had a hyperdynamic circulatory reaction 24–72 h after surgery. In conclusion, preoperative clonidine 150 μg, intrathecally or orally, prevented significant postoperative AWS in ethanol-dependent patients.

  • 2.
    Dobrydnjov, Igor
    et al.
    Departments of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Axelsson, Kjell
    Departments of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Thörn, S.-E.
    Departments of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Matthiesen, P.
    Department of Surgery, University Hospital, Örebro, Sweden.
    Klockhoff, H.
    Department of Surgery, University Hospital, Örebro, Sweden.
    Holmström, B.
    Departments of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Gupta, A.
    Departments of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Clonidine combined with small-dose bupivacaine during spinal anesthesia for inguinal herniorrhaphy: a randomized double-blinded study2003In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 96, no 5, p. 1496-1503Article in journal (Refereed)
    Abstract [en]

    The aim of this randomized double-blinded study was to see whether the addition of small-dose clonidine to small-dose bupivacaine for spinal anesthesia prolonged the duration of postoperative analgesia and also provided a sufficient block duration that would be adequate for inguinal herniorrhaphy. We randomized 45 patients to 3 groups receiving intrathecal hyperbaric bupivacaine 6 mg combined with saline (Group B), clonidine 15 μg (Group BC15), or clonidine 30 μg (Group BC30); all solutions were diluted with saline to 3 mL. The sensory block level was insufficient for surgery in five patients in Group B, and these patients were given general anesthesia. Patients in Groups BC15 and BC30 had a significantly higher spread of analgesia (two to four dermatomes) than those in Group B. Two-segment regression, return of S1 sensation, and regression of motor block were significantly longer in Group BC30 than in Group B. The addition of clonidine 15 and 30 μg to bupivacaine prolonged time to first analgesic request and decreased postoperative pain with minimal risk of hypotension. We conclude that clonidine 15 μg with bupivacaine 6 mg produced an effective spinal anesthesia and recommend this dose for inguinal herniorrhaphy, because it did not prolong the motor block.

  • 3.
    Ekbäck, Gustav
    et al.
    Departments of Anesthesiology and Intensive Care Örebro Medical Center Hospital.
    Axelsson, Kjell
    Department of Anesthesiology and Intensive Care Örebro Medical Center Hospital.
    Ryttberg, Lars
    Department of Orthopedic Surgery, Örebro Medical Center Hospital.
    Edlund, Bror
    Department of Clinical Chemistry, Örebro Medical Center Hospital.
    Kjellberg, Jill
    Department of Anesthesiology and Intensive Care Örebro Medical Center Hospital.
    Weckström, Johan
    Department of Orthopedic Surgery, Örebro Medical Center Hospital.
    Carlsson, Olle
    Department of Statistics, University of Örebro, Örebro, Sweden .
    Schött, Ulf
    Department of Anesthesiology and Intensive Care Örebro Medical Center Hospital.
    Tranexamic Acid Reduces Blood Loss in Total Hip Replacement Surgery2000In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 91, no 5, p. 1124-1130Article in journal (Refereed)
    Abstract [en]

    Intraoperatively administered, tranexamic acid (TA) does not reduce bleeding in total hip replacement (THR). Therefore, its prophylactic use was attempted in the present study because this has been shown to be more effective in cardiac surgery. We investigated 40 patients undergoing THR in a prospective, randomized, double-blinded study. Twenty patients received TA given in two bolus doses of 10 mg/kg each, the first just before surgical incision and the second 3 h later. In addition, a continuous infusion of TA, 1.0 mg · kg−1 · h−1 for 10 h, was given after the first bolus dose. The remaining 20 patients formed a control group. Both groups used preoperative autologous blood donation and intraoperative autotransfusion. Intraoperative bleeding was significantly less (P = 0.001) in the TA group compared with the control group (630 ± 220 mL vs 850 ± 260 mL). Postoperative drainage bleeding was correspondingly less (P = 0.001) (520 ± 280 vs 920 ± 410 mL). Up to 10 h postoperatively, plasma D-dimer concentration was halved in the TA group compared with the control group. One patient in each group had an ultrasound-verified late deep vein thrombosis. In conclusion, we found TA, administrated before surgical incision, to be efficient in reducing bleeding during THR.

  • 4.
    Ekman, A
    et al.
    Kalmar.
    Brudin, Lars
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Care, Clinical Physiology.
    Sandin, R
    Kalmar.
    A comparison of bispectral index and rapidly extracted auditory evoke potentials index responses to noxious stimulation during sevoflurane anesthesia2004In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 99, p. 1141-1146Article in journal (Refereed)
    Abstract [en]

       

  • 5.
    Ekman, A.
    et al.
    Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institute, Stockholm, Sweden, Department of Anesthesiology and Intensive Care, Regional Hospital, S-391 85, Kalmar, Sweden.
    Stalberg, E.
    Stålberg, E., Department of Clinical Neurophysiology, Uppsala University Hospital, Uppsala, Sweden.
    Sundman, E.
    Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institute, Stockholm, Sweden.
    Eriksson, L.I.
    Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institute, Stockholm, Sweden.
    Brudin, Lars
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Health Sciences, Clinical Physiology .
    Sandin, R.
    Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institute, Stockholm, Sweden.
    The effect of neuromuscular block and noxious stimulation on hypnosis monitoring during sevoflurane anesthesia2007In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 105, no 3, p. 688-695Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: There are conflicting results on the influence of neuromuscular block (NMB) on the bispectral index (BIS). We investigated the influence of two degrees of NMB on BIS, Alaris auditory-evoked potential index (AAI), and the electromyogram (EMG) obtained with needle electrodes from the frontal and temporal muscles, immediately adjacent to the BIS-sensor. METHODS: Twenty patients were anesthetized with sevoflurane, titrated for 30 min to an end-tidal concentration of 1.2% (baseline). Rocuronium was infused to 50% (partial) and 95% (profound) depression of the first twitch in a train-of-four response, the order being randomly chosen. Noxious tetanic electrical stimulation was applied at four occasions: 1) at baseline (control measurement), 2 and 3) at each degree of NMB, and 4) after neostigmine reversal. BIS, AAI, and EMG were obtained 2 min before and 2 min after each noxious stimulation. RESULTS: Median BIS and AAI at baseline were 44 (39-50) and 15 (14-16), respectively. The two degrees of NMB did not affect BIS, AAI, and EMG before noxious stimulation. In contrast, profound NMB altered the BIS and AAI responses to noxious stimulation when compared with partial NMB, (BIS P = 0.01, AAI P < 0.01), after neostigmine reversal (BIS P < 0.01, AAI P = 0.01) and compared with baseline (BIS P = 0.08, AAI P = 0.02). No significant increase in EMG was found. CONCLUSION: BIS and AAI responses to noxious tetanic electrical stimulation are affected by the degree of NMB during sevoflurane anesthesia whereas NMB does not affect BIS or AAI in the absence of noxious stimulation. © 2007 by International Anesthesia Research Society.

  • 6.
    Essving, Per
    et al.
    University Hospital, Örebro.
    Axelsson, Kjell
    University Hospital, Örebro.
    Aberg, Elisabeth
    University Hospital, Örebro.
    Spannar, Henrik
    University Hospital, Örebro.
    Gupta, Anil
    Linköping University, Department of Medical and Health Sciences, Anesthesiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Sinnescentrum, Department of Anaesthesiology and Surgery UHL.
    Lundin, Anders
    University Hospital, Örebro.
    Local Infiltration Analgesia Versus Intrathecal Morphine for Postoperative Pain Management After Total Knee Arthroplasty: A Randomized Controlled Trial2011In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 113, no 4, p. 926-933Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Local infiltration analgesia (LIA)-using a combination of local anesthetics, nonsteroidal anti-inflammatory drugs, and epinephrine, injected periarticularly during surgery-has become popular in postoperative pain management after total knee arthroplasty (TKA). We compared intrathecal morphine with LIA after TKA. less thanbrgreater than less thanbrgreater thanMETHODS: In this double-blind study, 50 patients scheduled to undergo TKA under spinal anesthesia were randomized into 2 groups: group M, 0.1 mg morphine was injected intrathecally together with the spinal anesthetic and in group L, LIA using ropivacaine, ketorolac, and epinephrine was infiltrated in the knee during the operation, and 2 bolus injections of the same mixture were given via an intraarticular catheter postoperatively. Postoperative pain, rescue analgesic requirements, mobilization, and home readiness were recorded. Patient-assessed health quality was recorded using the Oxford Knee Score and EQ-5D during 3 months follow-up. The primary endpoint was IV morphine consumption the first 48 postoperative hours. less thanbrgreater than less thanbrgreater thanRESULTS: Mean morphine consumption was significantly lower in group L than in group M during the first 48 postoperative hours: 26 +/- 15 vs 54 +/- 29 mg, i.e., a mean difference for each 24-hour period of 14.2 (95% confidence interval [CI] 7.6 to 20.9) mg. Pain scores at rest and on movement were lower during the first 48 hours in group L than in group M (P andlt; 0.001). Pain score was also lower when walking in group L than in group M at 24 hours and 48 hours postoperatively (P andlt; 0.001). In group L, more patients were able to climb stairs at 24 hours: 50% (11 of 22) versus 4% (1 of 23), i.e., a difference of 46% (95% CI 23.5 to 68.5) and at 48 hours: 70% (16 of 23) versus 22% (5 of 23), i.e., a difference of 48% (95% CI 23 to 73). Median (range) time to fulfillment of discharge criteria was shorter in group L than in group M, 51 (24-166) hours versus 72 (51-170) hours. The difference was 23 (95% CI 18 to 42) hours (P = 0.001). Length of hospital stay was also shorter in group L than in group M: median (range) 3 (2-17) versus 4 (2-14) days (P = 0.029). Patient satisfaction was greater in group L than in group M (P = 0.001), but no differences were found in knee function, side effects, or in patient-related outcomes, Oxford Knee score, or EQ-5D. less thanbrgreater than less thanbrgreater thanCONCLUSIONS: LIA technique provided better postoperative analgesia and earlier mobilization, resulting in shorter hospital stay, than did intrathecal morphine after TKA.

  • 7.
    Hahn, Robert G
    et al.
    Karolinska Institute, Stockholm, Sweden.
    Brauer, Lance
    University of Texas Medical Branch, Galveston, Texas, USA.
    Rodhe, Peter
    Karolinska Institute, Stockholm, Sweden.
    Svensén, Christer H
    University of Texas Medical Branch, Galveston, Texas, USA.
    Prough, Donald S
    University of Texas Medical Branch, Galveston, Texas, USA.
    Isoflurane inhibits compensatory intravascular volume expansion after hemorrhage in sheep2006In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 103, no 2, p. 350-358Article in journal (Refereed)
    Abstract [en]

    After hemorrhage, blood volume is partially restored by transcapillary refill, a process of spontaneous compensatory intravascular volume expansion that we hypothesized would be inhibited by anesthesia. Six chronically instrumented sheep were subjected to four randomly ordered experiments while conscious or during anesthesia with isoflurane. After plasma volume measurement (indocyanine green), 15% or 45% of the blood volume was withdrawn. To quantify transcapillary refill, mass balance and kinetic calculations utilized repeated measurements of hemoglobin concentration, assuming that transcapillary refill would dilute hemoglobin concentration. After 15% hemorrhage, mean arterial blood pressure remained stable in both conscious and isoflurane-anesthetized sheep (normotensive hemorrhage) but decreased after 45% hemorrhage (hypotensive hemorrhage). After either normotensive or hypotensive hemorrhage, transcapillary refill occurred more rapidly during the first 40 min than during the next 140 min (P < 0.001). In conscious sheep, at 180 min, 57% and 42% of the bled volume had been restored after normotensive and hypotensive hemorrhage, respectively, in contrast to only 13% and 27% (P < 0.001) in isoflurane-anesthetized sheep. A novel kinetic model implicated hemodynamic factors in rapid, early transcapillary refill and decreased plasma oncotic pressure in subsequent slower filling. We conclude that isoflurane inhibits transcapillary refill after both normotensive and hypotensive hemorrhage in sheep.

  • 8.
    Johansson, Mats
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Escobar Kvitting, John-Peder
    Linköping University, Department of Medical and Health Sciences, Division of Radiological Sciences. Linköping University, Center for Medical Image Science and Visualization (CMIV). Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Flatebø, Torun
    Department of Physiology, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Norway.
    Nicolaysen, Anne
    Department of Physiology, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Norway.
    Nicolaysen, Gunnar
    Department of Physiology, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Norway.
    Walther, Sten
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Inhibition of constitutive nitric oxide synthase does not influence ventilation: matching in normal prone adult sheep with mechanical ventilation2016In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 123, no 6, p. 1492-1499Article in journal (Refereed)
    Abstract [en]

    Background

    Local formation of nitric oxide (NO) in the lung in proportion to ventilation, leading to vasodilation, is a putative mechanism behind ventilation- perfusion matching. We examined the role of local constitutive NO formation on regional distributions of ventilation (V) and perfusion (Q) and ventilation-perfusion matching (V/Q) in mechanically ventilated adult sheep with normal gas exchange.

    Methods

    V and Q were analyzed in lung regions (≈1.5 cm3) before and after inhibition of constitutive nitric oxide synthase (cNOS) with Nω-nitro-L-arginine methyl ester (L-NAME) (25 mg/kg) in seven prone sheep ventilated with PEEP. V and Q were measured using aerosolized fluorescent and infused radiolabeled microspheres, respectively. The animals were exsanguinated while deeply anaesthetized; lungs were excised, dried at total lung capacity and divided into cube units. The spatial location for each cube was tracked and fluorescence and radioactivity per unit weight determined.

    Results

    Pulmonary artery pressure increased significantly after L-NAME (from mean 16.6 to 23.6 mmHg, P<0.01) while there were no significant changes in PaO2, PaCO2 or SD log(V/Q). Distribution of V was not influenced by L-NAME but a small redistribution of Q from ventral to dorsal lung regions resulting in less heterogeneity in Q along the gravitational axis was seen (p<0.01). Perfusion to regions with the highest ventilation (5th quintile of the V distribution) remained unchanged with L-NAME.

    Conclusions

    There was minimal or no influence of cNOS inhibition by L-NAME on the distributions of V and Q, and V/Q in prone anesthetized and ventilated adult sheep with normal gas exchange.

  • 9.
    Klaastad, O.
    et al.
    Klaastad, Ø., Department of Anesthesiology, Interventional Centre, Rikshospitalet University Hospital, Oslo, Norway, Rikshospitalet University Hospital, Department of Anesthesiology, Sognsvannsveien 20, NO-0027 Oslo, Norway.
    Smedby, Örjan
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Health Sciences, Radiology . Östergötlands Läns Landsting, Centre for Medical Imaging, Department of Radiology in Linköping.
    Kjelstrup, T.
    Department of Anesthesiology, Rikshospitalet University Hospital, Oslo, Norway.
    Smith, H.-J.
    Department of Radiology, Rikshospitalet University Hospital, Oslo, Norway.
    The vertical infraclavicular brachial plexus block: A simulation study using magnetic resonance imaging2005In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 101, no 1, p. 273-278Article in journal (Refereed)
    Abstract [en]

    The recommended needle trajectory for the vertical infraclavicular brachial plexus block is anteroposterior, caudad to the middle of the clavicle. We studied the risk of pneumothorax and subclavian vessel puncture and the precision of this method by using magnetic resonance imaging in 20 adult volunteers. The trajectory aimed at the lung in six subjects, five of whom were women. However, pleural contact could be avoided in all subjects by halting needle advancement after contact with the subclavian vessels, plexus, or first rib. The subclavian vein was reached by the trajectory in three and the subclavian artery in five subjects. The trajectory had a median distance to the plexus (closest aspect) of 1 mm (range, 0-9 mm) and contacted the nerves in 9 subjects. In conclusion, there is a small probability that the needle may reach the pleura when a vertical infraclavicular brachial plexus block is performed, particularly in women, and a high probability that it will contact the subclavian vein or artery. Although the trajectory is close to the plexus, any medial deviation carries the risk of pleural or subclavian vessel contact at other depths. Clinical accuracy in defining the insertion point is critical. © 2005 by the International Anesthesia Research Society.

  • 10.
    Klaastad, O
    et al.
    University of Oslo .
    Smith, HJ
    University of Oslo .
    Smedby, Örjan
    Linköping University, Department of Medical and Health Sciences, Radiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre for Medical Imaging, Department of Radiology in Linköping. Linköping University, Center for Medical Image Science and Visualization, CMIV.
    Winther-Larssen, EH
    University of Oslo .
    Brodal, P
    University of Oslo .
    Breivik, H
    University of Oslo .
    Fosse, ET
    University of Oslo .
    Letter: A novel approach to infraclavicular brachial plexus block: The ultrasound experience - In response2004In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 99, no 3, p. 950-951Article in journal (Other academic)
    Abstract [en]

    n/a

  • 11.
    Klaastad, O
    et al.
    Oslo.
    VadeBoncouer, TR
    Chicago.
    Tillung, T
    Oslo.
    Smedby, Örjan
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Care, Radiology. Östergötlands Läns Landsting, Centre for Medical Imaging, Department of Radiology UHL. Linköping University, Center for Medical Image Science and Visualization, CMIV.
    An evaluation of the supraclavicular plumb-bob technique for brachial plexus block by magnetic resonance imaging2003In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 96, no 3, p. 862-867Article in journal (Refereed)
    Abstract [en]

    Partly based on magnetic resonance imaging studies, the "plumb-bob" approach for brachial plexus block was designed to minimize the risk of pneumothorax. Nevertheless, the risk of pneumothorax has remained a concern. We analyzed magnetic resonance images from 10 volunteers to determine whether the risk of pneumothorax was decreased with this method. The recommended initial needle direction is anteroposterior through the junction between the lateral-most part of the sternocleidomastoid muscle and the superior edge of the clavicle. If the initial placement is not successful, the brachial plexus may be sought in sectors 20░-30░ cephalad or caudad to the anteroposterior line in a sagittal plane through the insertion point. We found that the anteroposterior line reached the pleura in 6 of 10 volunteers without prior contact with the subclavian artery or the brachial plexus, but always with contact with the subclavian vein. To reach the middle of the brachial plexus, a mean cephalad redirection of the simulated needle by 21░ was required (range from 41░ cephalad to 15░ caudad in one case). We conclude that the risk of contacting the pleura and the subclavian vessels may be reduced by initially directing the needle 45░ cephalad instead of anteroposterior. If the brachial plexus is not contacted, the angle should be gradually reduced.

  • 12.
    Klaastad, Öivind
    et al.
    Olso.
    Smedby, Örjan
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Care, Radiology. Östergötlands Läns Landsting, Centre for Medical Imaging, Department of Radiology UHL.
    The supraclavicular lateral paravascular approach for brachial plexus regional anesthesia: A simulation study using magnetic resonance imaging2001In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 93, no 2, p. 442-446Article in journal (Refereed)
    Abstract [en]

    In the supraclavicular lateral paravascular approach for brachial plexus regional anesthesia by Moorthy et al. (Moorthy's block), the patient is supine with the ipsilateral shoulder displaced anteriorly 5-8 cm. The needle direction is precisely defined in the coronal plane (using a Doppler flowprobe) but not in the sagittal plane. We sought to determine whether the block could be simplified by keeping the shoulder in a neutral position, if the needle direction in the sagittal plane could be more precisely described, and if the risk of pneumothorax appeared acceptably small. These questions were studied by magnetic resonance imaging in 10 volunteers. Volume datasets of the periclavicular region allowed precise positioning of simulated needles. In all volunteers, Moorthy's block could be performed with the shoulder in a neutral position. The optimal needle trajectory passed 5 mm posterior to the clavicle and was 25░ posterior to the coronal plane, never approaching the pleura closer than 18 mm. We conclude that Moorthy's block can be performed with the shoulder in a neutral position, that more precise instructions for the needle direction can be given, and that the risk of pneumothorax seems minimal. This should be confirmed by a clinical study.

  • 13.
    Klaastad, Øivind
    et al.
    Department of Anesthesiology, Rikshospitalet University Hospital, Oslo, Norway.
    Smith, Hans-Jørgen
    Department of Radiology, Rikshospitalet University Hospital, Oslo, Norway.
    Smedby, Örjan
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medical and Health Sciences, Radiology. Östergötlands Läns Landsting, Centre for Medical Imaging, Department of Radiology in Linköping. Linköping University, Center for Medical Image Science and Visualization (CMIV).
    Winther-Larssen, Eldrid H.
    Department of Radiology, Rikshospitalet University Hospital, Oslo, Norway.
    Brodal, Per
    Department of Anatomy, University of Oslo, Oslo, Norway.
    Breivik, Harald
    Department of Anesthesiology, Rikshospitalet University Hospital, Oslo, Norway.
    Fosse, Erik T.
    The Interventional Centre, Rikshospitalet University Hospital, Oslo, Norway.
    A novel infraclavicular brachial plexus block: The lateral and sagittal technique, developed by magnetic resonance imaging studies2004In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 98, no 1, p. 252-256Article in journal (Refereed)
    Abstract [en]

    A new infraclavicular brachial plexus block method has the patient supine with an adducted arm. The target is any of the three cords behind the pectoralis minor muscle. The point of needle insertion is the intersection between the clavicle and the coracoid process. The needle is advanced 0degrees-30degrees posterior, always strictly in the sagittal plane next to the coracoid process while abutting the antero-inferior edge of the clavicle. We tested the new method using magnetic resonance imaging (MRI) in 20 adult volunteers, without inserting a needle. Combining 2 simulated needle directions by 15degrees posterior and 0degrees in the images of the volunteers, at least one cord in 19 of 20 volunteers was contacted. This occurred within a needle depth of 6.5 cm. In the sagittal plane of the method the shortest depth to the pleura among all volunteers was 7.5 cm. The MRI study indicates that the new infraclavicular technique may be efficient in reaching a cord of the brachial plexus, often not demanding more than two needle directions. The risk of pneumothorax should be minimal because the needle is inserted no deeper than 6.5 cm. However, this needs to be confirmed by a clinical study.

  • 14.
    Lindholm, Maj-Lis
    et al.
    Östergötlands Läns Landsting.
    Brudin, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences.
    Sandin, Rolf H.
    Karolinska Institute, Sweden .
    Cumulated Time With Low Bispectral Index Values Is Not Related to the Risk of New Cancer or Death Within 5 Years After Surgery in Patients With Previous or Prevailing Malignancy2014In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 118, no 4, p. 782-787Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Preclinical data indicate that anesthesia and surgery may promote cancer growth. We previously found no increased risk of malignant disease within 5 years regarding duration of general anesthesia (T-ANESTH) and time with Bispectral Index (BIS) under 45 (T-BIS less than 45) in patients without any diagnosis or history of malignancy before or within 1 month after surgery. Because immunocompetence may be different in patients with previous malignant disease, we investigated the corresponding risk in patients with earlier or existing malignant disease at the time of surgery. METHODS: In a prospective cohort of 766 BIS-monitored patients anesthetized with sevoflurane, new malignant diagnoses and death within 5 years after surgery were retrieved. Cox regression was used to assess the risk of new cancer and all-cause death during follow-up in relation to (T-ANESTH) and (T-BIS less than45). RESULT: Fifty-one patients (6.7%) were assigned 54 new malignant diagnoses within 5 years after surgery. Cancer surgery comprised 387 (51%) of the index operations. Two hundred ninety-three (38 %) of the patients died during follow-up. No relation between T-ANESTH or T-BIS less than45 and new malignant disease (hazard ratio [HR] 0.64-1.11 and 0.76-1.30, respectively) or death was found (HR 0.85-1.05 and 0.94-1.16, respectively). Nor were any corresponding significant relations obtained when other thresholds for BIS (i.e., less than 30, 40, and 50, respectively) were investigated. CONCLUSION: In patients with previous or existing malignant disease, neither duration of anesthesia nor increased cumulative time with profound sevoflurane anesthesia was associated with an increased risk for new cancer or death within 5 years after surgery. Monitoring depth of anesthesia is not expected to alter the risk of cancer proliferation after surgery.

  • 15.
    Lisander, Björn
    et al.
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Health Sciences, Anesthesiology .
    Hahn, R
    Linkoping Univ Hosp, Dept Anesthesia, S-58185 Linkoping, Sweden Karolinska Inst, Stockholm, Sweden.
    Hemostasis in patients of different ABO blood groups2002In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 95, no 1, p. 254-255Other (Other academic)
  • 16.
    Nilsson, Lena
    Linköping University, Department of Medical and Health Sciences, Anesthesiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Department of Anaesthesiology and Intensive Care in Linköping.
    Respiration Signals from Photoplethysmography2013In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 117, no 4, p. 859-865Article in journal (Refereed)
    Abstract [en]

    Pulse oximetry is based on the technique of photoplethysmography (PPG) wherein light transmitted through tissues is modulated by the pulse. In addition to variations in light modulation by the cardiac cycle, the PPG signal contains a respiratory modulation and variations associated with changing tissue blood volume of other origins. Cardiovascular, respiratory, and neural fluctuations in the PPG signal are of different frequencies and can all be characterized according to their sinusoidal components. PPG was described in 1937 to measure blood volume changes. The technique is today increasingly used, in part because of developments in semiconductor technology during recent decades that have resulted in considerable advances in PPG probe design. Artificial neural networks help to detect complex nonlinear relationships and are extensively used in electronic signal analysis, including PPG. Patient and/or probe-tissue movement artifacts are sources of signal interference. Physiologic variations such as vasoconstriction, a deep gasp, or yawn also affect the signal. Monitoring respiratory rates from PPG are often based on respiratory-induced intensity variations (RIIVs) contained in the baseline of the PPG signal. Qualitative RIIV signals may be used for monitoring purposes regardless of age, gender, anesthesia, and mode of ventilation. Detection of breaths in adult volunteers had a maximal error of 8%, and in infants the rates of overdetected and missed breaths using PPG were 1.5% and 2.7%, respectively. During central apnea, the rhythmic RIIV signals caused by variations in intrathoracic pressure disappear. PPG has been evaluated for detecting airway obstruction with a sensitivity of 75% and a specificity of 85%. The RIIV and the pulse synchronous PPG waveform are sensitive for detecting hypovolemia. The respiratory synchronous variation of the PPG pulse amplitude is an accurate predictor of fluid responsiveness. Pleth variability index is a continuous measure of the respiratory modulation of the pulse oximeter waveform and has been shown to predict fluid responsiveness in mechanically ventilated patients including infants. The pleth variability index value depends on the size of the tidal volume and on positive end-expiratory pressure. In conclusion, the respiration modulation of the PPG signal can be used to monitor respiratory rate. It is probable that improvements in neural network technology will increase sensitivity and specificity for detecting both central and obstructive apnea. The size of the PPG respiration variation can predict fluid responsiveness in mechanically ventilated patients.

  • 17.
    Piros, David
    et al.
    Karolinska Institutet, Söder Hospital, Stockholm, Sweden, .
    Fagerström, Tim
    Karolinska Institutet, Söder Hospital, Stockholm, Sweden.
    Collins, Justin W.
    Bristol Urological Institute, UK.
    Hahn, Robert G.
    Södertälje Hospital, Sweden.
    Glucose as a marker of fluid absorption in bipolar transurethral surgery2009In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 109, no 6, p. 1850-1855Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Historically, a reduced serum sodium concentration has been used to diagnose absorption of electrolyte-free irrigating fluid during transurethral resection of the prostate (TURP). In bipolar TURP, the irrigating solution contains electrolytes, thus invalidating the serum sodium method. In this study, we investigated whether glucose can be used to diagnose the absorption of irrigating fluid during TURP procedures.

    METHODS: The serum glucose and sodium concentrations were measured in 250 patients undergoing monopolar TURP using either 1.5% glycine or 5% glucose for urinary bladder irrigation. The glucose kinetics was analyzed in 10 volunteers receiving a 30-min infusion of 20 mL/kg of acetated Ringer's solution with 1% glucose. These data were then used in computer simulations of different absorption patterns that were summarized in a nomogram for the relationship between the glucose level and administered fluid volume.

    RESULTS: There was a statistically significant inverse linear relationship between the decrease in serum sodium and the increase in glucose levels after absorption of 5% glucose during TURP (r(2) = 0.80). The glucose concentration increased, from 4.6 (sd 0.4) to 8.3 (0.9) mmol/L, during the experimental infusions. Regardless of the absorption pattern, all simulations indicated that the uptake of 1 L of fluid containing 1% glucose corresponded to an increase in the glucose level of 3.7 (sd 1.6) mmol/L at the end of surgery, whereas 2 L yielded an increase of 6.9 (1.7) mmol/L.

    CONCLUSIONS: In bipolar TURP, the addition of glucose to a concentration of 1% in the electrolyte-containing irrigation fluid can be used as a tracer of absorption that is comparable with measuring serum sodium after monopolar TURP.

  • 18.
    Svensen, Christer H
    et al.
    University of Texas Medical Branch, Galveston, USA.
    Rodhe, Peter M
    Karolinska institutet, Söder Hospital, Stockholm, Sweden.
    Olsson, Joel
    University of Texas Medical Branch, Galveston, USA.
    Børsheim, Elisabet
    University of Texas Medical Branch, Galveston, USA.
    Aarsland, Asle
    University of Texas Medical Branch, Galveston, USA.
    Hahn, Robert G
    Clinical Research Center, Södertälje, Sweden.
    Arteriovenous differences in plasma dilution and the distribution kinetics of lactated ringer's solution2009In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 108, no 1, p. 128-133Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Conventional concept suggests that infused crystalloid fluid is first distributed in the plasma volume and then, since the capillary permeability for fluid is very high, almost instantly equilibrates with the extracellular fluid space. We challenge whether this view is consistent with findings based on volume kinetic analysis.

    METHODS: Fifteen volunteers received an IV infusion of 15 mL/kg of lactated Ringer's solution during 10 min. Simultaneous arterial and venous blood hemoglobin (Hgb) samples were obtained and Hgb concentrations measured. The arteriovenous (AV) difference in Hgb dilution in the forearm was determined and a volume kinetic model was fitted to the series of Hgb concentrations in arterial and venous blood.

    RESULTS: The AV difference in plasma dilution was only positive during the infusion and for 2.5 min thereafter, which represents the period of net flow of fluid from plasma to tissue. Kinetic analysis showed that volume expansion of the peripheral fluid space began to decrease 14 min (arterial blood) and 20 min (venous blood) after the infusion ended. Distribution of lactated Ringer's solution apparently occurs much faster in the forearm than in the body as a whole. Therefore, the AV difference in the arm does not accurately reflect the distribution of Ringer's solutions or whole-body changes in plasma volume.

    CONCLUSIONS: The relatively slow whole-body distribution of lactated Ringer's solution, which boosts the plasma volume expansion during and for up to 30 min after an infusion, is probably governed by a joint effect of capillary permeability and differences in tissue perfusion between body regions.

  • 19.
    Svensén, Christer H
    et al.
    University of Texas Medical Branch, Galveston, USA.
    Olsson, Joel
    University of Texas Medical Branch, Galveston, USA.
    Hahn, Robert G
    Karolinska Institute, Stockholm, Sweden.
    Intravascular fluid administration and hemodynamic performance during open abdominal surgery2006In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 103, no 3, p. 671-676Article in journal (Refereed)
    Abstract [en]

    We studied whether central hemodynamics measured by a pulmonary artery catheter can serve as a pharmacodynamic expression of fluid therapy in 10 patients undergoing open abdominal surgery. We examined how closely hemodynamic variables follow plasma dilution, which is an index of plasma volume expansion, during and after an IV infusion of 25 mL/kg of lactated Ringer's solution over 45 min. Pulmonary artery wedge pressure and central venous pressure responded to IV fluid with an increase that correlated with accompanying plasma dilution. Six of 10 patients showed a decrease in cardiac output that was probably secondary to an increase in peripheral vascular resistance (nonresponders), whereas the rest increased cardiac output (responders). Volume kinetic analysis suggested that 54% of the infused fluid resided in the central fluid space at the end of the infusion and 25% at the end of the study in the responders compared with 25% and 3%, respectively, in nonresponders. In conclusion, half of the patients undergoing open abdominal surgery responded to crystalloid fluid with a decrease in cardiac output. Pulmonary artery wedge pressure and central venous pressure responded more consistently to different degrees of plasma dilution, which can be simulated for various fluid regimens using volume kinetics.

  • 20.
    Walldén, Jakob
    et al.
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Health Sciences, Anesthesiology .
    Thorn, SE
    Wattwil, Magnus
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Care.
    The delay of gastric emptying induced by remifentanil is not influenced by posture2004In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 99, no 2, p. 429-434Article in journal (Refereed)
    Abstract [en]

    Posture has an effect on gastric emptying. In this study, we investigated whether posture influences the delay in gastric emptying induced by opioid analgesics. Ten healthy male subjects underwent 4 gastric emptying studies with the acetaminophen method. On two occasions the subjects were given a continuous infusion of remifentanil (0.2 mug . kg(-1) . min(-1)) while lying either on the right lateral side in a 20degrees head-up position or on the left lateral side in a 20degrees head-down position. On two other occasions no infusion was given, and the subjects were studied lying in the two positions. When remifentanil was given, there were no significant differences between the two postures in maximal acetaminophen concentration (right side, 34 mumol . L-1, versus left side, 16 mumol . L-1), time taken to reach the maximal concentration (94 versus 109 min), or area under the serum acetaminophen concentration time curve from 0 to 60 min (962 versus 197 min . mumol - L-1). In the control situation, there were differences between the postures in maximal acetaminophen concentration (138 versus 94 mumol . L-1, P < 0.0001) and area under the serum acetaminophen concentration time curves from 0 to 60 min (5092 versus 3793 min . mumol . L-1, P < 0.0001), but there was no significant difference in time taken to reach the maximal concentration (25 versus 47 min). Compared with the control situation, remifentanil delayed gastric emptying in both postures. We conclude that remifentanil delays gastric emptying and that this delay is not influenced by posture.

  • 21.
    Wattwil, Magnus
    et al.
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Care.
    Thorn, SE
    Lovqvist, A
    Wattwil, L
    Klockhoff, H
    Larsson, LG
    Naslund, I
    Perioperative gastric emptying is not a predictor of early postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy2002In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 95, no 2, p. 476-479Article in journal (Refereed)
    Abstract [en]

    It is not known whether patients with postoperative nausea and vomiting (PONV) have delayed gastric emptying compared with patients without PONV. We compared the perioperative rate of gastric emptying in patients experiencing PONV with the rate in those without PONV immediately after laparoscopic cholecystectomy. Gastric emptying was studied by the acetaminophen method. Acetaminophen is not absorbed from the stomach but is rapidly absorbed from the small intestine, and the rate of gastric emptying therefore determines the rate of absorption of acetaminophen administered into the stomach. Forty patients (ASA physical status I and II) were included in the study. After the induction of anesthesia, a gastric tube was positioned in the stomach and 1.5 g of acetaminophen dissolved in 200 mL of water was administered. Venous blood samples for the determination of serum acetaminophen concentrations were taken before and at 15-min intervals during a period of 180 min after the administration of acetaminophen. Twenty-six patients experienced nausea during the first 4 h postoperatively. The other 14 patients had no nausea. There were no statistically significant differences in the maximal acetaminophen concentration, the time taken to reach the maximal concentration, or the area under the serum acetaminophen concentration time curves from 0 to 60, 0-120, and 0-180 min between the groups of patients with or without PONV. We did not find any relationship between postoperative gastric emptying and PONV, and therefore gastric emptying is not a predictor of PONV.

  • 22.
    Zdolsek, Joachim
    et al.
    Linköping University, Department of Medical and Health Sciences, Anesthesiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Sinnescentrum, Department of Anaesthesiology and Surgery UHL.
    Li, Yuhong
    Linköping University, Department of Medical and Health Sciences, Anesthesiology. Linköping University, Faculty of Health Sciences.
    Hahn, Robert G
    Linköping University, Department of Medical and Health Sciences, Anesthesiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Sinnescentrum, Department of Anaesthesiology and Surgery UHL.
    Detection of Dehydration by Using Volume Kinetics2012In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 115, no 4, p. 814-822Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Patients admitted to surgery may be dehydrated, which is difficult to diagnose except when it is severe (>5% Gl116 of the body weight). We hypothesized that modest dehydration can be detected by kinetic analysis of the blood hemoglobin concentration after a bolus infusion of crystalloid fluid.

    METHODS: Four series of experiments were performed on 10 conscious, healthy male volunteers. Separated by at least 2 days, they received 5 or 10 mL/kg acetated Ringer's solution over 15 minutes. Before starting half of the IV infusions, volume depletion amounting to 1.5 to 2.0 L (approximately 2% of body weight) was induced with furosemide. The elimination clearance and the half-life of the infused fluid were calculated based on blood hemoglobin over 120 minutes. The perfusion index and the pleth variability index were monitored by pulse oximetry after a change of body position.

    RESULTS: Dehydration decreased the elimination clearance of acetated Ringer's solution [median (25th-75th percentile)] from 1.84 (1.23-2.57) to 0.53 (0.41-0.79) mL/kg/min (Wilcoxon matched-pair test P < 0.001) and increased the half-life from 23 (12-37) to 76 (57-101) minutes (P < 0.001). The smaller infusion, 5 mL/kg, fully discriminated between experiments performed in the euhydrated and dehydrated states, whereas the urinary excretion provided a less-reliable indication of hydration status. Dehydration decreased the perfusion index but did not affect the pleth variability index.

    CONCLUSION: Dehydration amounting to 2% of the body weight could be detected from the elimination clearance and the half-life of an infusion of 5 mL/kg Ringer's solution.

  • 23.
    Zdolsek, Joachim
    et al.
    Östergötlands Läns Landsting, Anaesthesiology and Surgical Centre, Department of Intensive Care UHL.
    Lisander, Björn
    Linköping University, Department of Medical and Health Sciences, Anesthesiology. Linköping University, Faculty of Health Sciences.
    Hahn, Robert G.
    Department of Anesthesiology, Karolinska Institute, Stockholm, Sweden.
    Measuring the size of the extracellular fluid space using bromide, iohexol, and sodium dilution2005In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 101, no 6, p. 1770-1777Article in journal (Refereed)
    Abstract [en]

    There is a need to find methods to assess the size of the extracellular fluid (ECF) volume without involving radioactive tracers. For this purpose, we applied 3 methods for measuring the ECF volume in 10 male volunteers (mean age, 34 yr). Steady-state plasma bromide concentration (control) was compared to the results of kinetic analysis of plasma iohexol and to kinetic analysis of the dilution of serum sodium after IV infusion of 1 L of isotonic mannitol. The volume of distribution of these tracers was used to indicate the ECF volume. The results disclosed statistically significant correlations between the results of all 3 methods, although the average sodium dilution showed 0.7 L lower values than iohexol and 1.4 L lower than bromide. All three methods correlated significantly with body weight. The percentage of the body weight indicated by the methods was 18.3% (3.1%) for sodium, 19.6% (1.0%) for iohexol, and 20.5% (1.1%) for bromide. We conclude that sodium dilution may be performed at bedside but iohexol and bromide showed less intersubject variability. Iohexol simultaneously measures the glomerular filtration rate and should be a viable clinical option if the hospital performs routine assessments of kidney function using this tracer. ©2005 by the International Anesthesia Research Society.

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